Evaluation of Computed Tomography as a Screening Test for Death Inquest

Abstract: The Japanese method of inquest, which depends mostly on external examinations, may misdiagnose a considerable number of accidental deaths and suicides as death by disease. We conducted computed tomography (CT) scans of 80 cases for which police concluded death by disease or natural causes based on police investigations into the circumstances and results from external examinations. The cause of death was clearly determined by CT scan in 17 of 80 cases. Ten cases underwent autopsy after the police suspected criminality based on results of the CT examinations. The results suggest CT scan may be a tool for preventing a number of overlooked crimes and accidents in Japan. However, it cannot be a perfect tool for discerning between death by disease and other causes of death without cooperation from the investigative agencies and subsequent forensic examinations such as autopsy and toxicological tests.     

A retrospective analysis of cardiovascular deaths: A 5-year autopsy study of 1045 cases in Antalya,Turkey

This study aims to identify the macroscopic and microscopic changes that occur in the heart in different causes of cardiovascular death and sudden cardiac death in autopsy cases and evaluate the difficulties that a forensic practitioner may encounter during autopsies. All forensic autopsy cases in the Morgue Department of the Council of Forensic Medicine, Antalya Group Administration between January 1, 2015, and December 31, 2019, were examined, retrospectively. The cases were chosen according to inclusion and exclusion criteria, and their autopsy reports were examined in detail. It was determined that 1045 cases met the study criteria, 735 of which were also met the sudden cardiac death criteria. The top three common causes of death were ischemic heart disease (n = 719, 68.8%), left ventricular hypertrophy (n = 105, 10%), and aortic dissection (n = 58, 5.5%). The frequency of myocardial interstitial fibrosis was significantly higher in deaths due to left ventricular hypertrophy than in deaths due to ischemic heart disease and other causes (χ²(2) = 33.365, p < 0.001). Despite detailed autopsy and histopathological examinations, some heart diseases that cause sudden death may still not be detected.     

Pathologic Findings of Coronary Stents: A Comparison of Sudden Coronary Death Versus Non‐cardiac Death

There are few histologic studies of intracoronary stents found at autopsy. We studied histologic findings of 87 intracoronary stents from 45 autopsy hearts. There were 40 patients with chronically implanted stents and five shorter than 30 days. Of five patients with recent stent placement, the cause of death was related to the stent (in‐stent thrombosis) in one case. Of the 40 patients with chronic stents, there were 16 sudden coronary deaths and 24 noncoronary deaths (controls). There were no late stent thromboses in the coronary deaths. In the coronary deaths, 26% of stents showed restenosis versus 11% in controls (p = 0.1). The rate of healed infarcts and cardiomegaly was similar in the coronary and noncoronary groups, and acute thrombi in native arteries were seen only in three hearts in the coronary group. We conclude that the cause of death is rarely impacted by in‐stent findings at autopsy, especially in chronically implanted stents.     

Death in sauna

Bathing in sauna is common in Finland, where there are approximately 2 million saunas among the population of 5.2 million. In this paper, deaths occurring while in a sauna in 1990-2002 in Finland were studied by analyzing police and forensic autopsy reports, death certificates, and toxicological results. The annual rate of death occurring while in a sauna was less than 2 per 100,000 inhabitants. Close to half (51%) of the cases were determined to be natural deaths and exposure to heat was the cause of death in 25%. Overall, 50% of all cases were under the influence of alcohol. The main conclusion is that death in the sauna is a rare event even in Finland where the frequency of sauna bathing is high. The role of alcohol as a risk factor has grown. The prevention of these deaths should focus on less drinking of alcohol and avoid leaving a drunken bather alone in the sauna.     

Causes of death of patients in an institution for the developmentally disabled

The causes of death of 53 severely to profoundly developmentally disabled patients who died in an intermediate care facility were reviewed. Respiratory disease, predominantly pneumonia and aspiration, accounted for 72% of deaths. Seven patients died of nonrespiratory causes, and in 8 patients, no cause of death could be determined, even after a complete autopsy or investigation. The median age at death was 20 years. The weights of these patients' organs at autopsy were lower than those for normal individuals of the same age. The lifespan of these severely impaired individuals continues to be significantly shortened, even with improved methods of care.     

Accuracy of cause of death determination without forensic autopsy examination

Medical examiners and coroners commonly determine cause and manner of death without an autopsy examination. Some death certificates generated in this way may not state the correct cause and manner of death. From the case files of the Department of Forensic Medicine in Sydney, Australia, the authors retrospectively reviewed investigative information of all cases in a 6-month period that were initially considered natural deaths (429). The authors, blinded to autopsy results, accepted 261 cases as appropriate for certification without autopsy and assigned a cause of death to each. Per standard local practice, all cases had been autopsied. The actual causes of death as determined by autopsy were then revealed and compared with the presumed causes of death. Most presumed and actual causes of death were cardiovascular (94% and 80%, respectively). The majority of presumed causes of death were listed as ASCVD as the cases lacked features of a more specific cardiovascular process. A large majority of cases had a presumed cause of death of ischemic heart disease based on individual case details. The actual causes of death demonstrated a large breadth of cardiovascular and noncardiovascular disease processes, even though ischemic heart disease accounted for 62% of deaths. The presumed cause of death was completely wrong in 28% of cases. A nonnatural manner of death was present in 3% of cases. This study demonstrates that experienced forensic pathologists may generate erroneous death certificates for cases that are not autopsied.     

Phencyclidine: a 5-year retrospective review from the New York City Medical Examiner's Office

We report here a 5-year retrospective review of autopsy cases from the New York City Medical Examiner's Office that demonstrated phencyclidine (PCP) in the blood. There were a total of 138 cases. There were 52 deaths because of mixed drug intoxication: the blood PCP concentrations in these cases ranged from <1 to 598 ng/mL. There were 80 violent deaths in which PCP was quantified in the blood but was unrelated to the cause of death. There were five nonviolent deaths in which PCP exclusively was detected. In four of these, there were preexisting medical conditions that could also have contributed to death. In these, the highest PCP concentration was 361.3 ng/mL, a concentration lower than seven of the individuals in our violent death category. This suggests that lower concentrations may be fatal with comorbid conditions.     

Undetermined Manner of Death: An Autopsy Series

A manner of death may be ruled undetermined by the forensic pathologist when there is insufficient information about the circumstances surrounding the death to make a ruling. The aim of our study was to retrospectively analyze a series of autopsy cases that were classified as undetermined manner of death after complete investigations. In all, 48 cases were examined. In 23 cases (48%), the cause of death was determined. The most frequent cause of death was toxic death (n = 11). More than one manner of death was deemed conceivable for most cases (n = 39). The most frequent and the most probable manner of death was accident (n = 37). Homicide was not excluded in about 23% of the cases. Our study showed that the manner of death may remain undetermined despite an established cause of death, and even when two or more conceivable causes of death are considered. Our study pointed out that undetermined manner of death covers a wide range of situations and that homicide may be underestimated.     

Uncertainty of determining cause of death in a medicolegal material without autopsy. An autopsy study

In constrast to other studies, this investigation was made on cases of medicolegal deaths that would not normally be autopsied. 223 females and 322 males, whose deaths were found to be natural before as well as after autopsy, were studied. The cause of death was estimated by external medicolegal examination, and after autopsy.In 79 females and 109 males, i.e. 35% and 34% respectively, estimated cause of death was found to be different after the autopsy. This was mostly because ischaemic heart disease as a cause of death was overestimated at the external medicolegal examination. No constant relationship between differing causes of death and age group could be demonstrated. Underdiagnoses and overdiagnoses tended to outweigh each other. Pneumonia, pulmonary embolism, cor pulmonale and aortic stenosis were clearly underestimated before autopsy. In addition, a variety of diseases that were not even mentioned at the medicolegal examination was found (subarachnoid haemorrhage, uraemia, perforated and bleeding gastric ulcers, tuberculosis).The same unreliability in the estimated cause of death therefore exists among cases not normally autopsied as found in retrospective studies of cases where autopsy is performed under all circumstances at the request of the police.False information will thus be given to the mortality statistics among the approximately 5000 cases of medicolegal deaths not autopsied in Denmark per year, most of these being natural deaths. Besides, contagious and inherited diseases could be overlooked, relatives given false information and the value of scientific studies in causes of death diminished.The conclusion is that autopsy is still essential to ensure continuous control and correction of causes of death.     

Use of "therapeutic complication" as a manner of death

Analyses of deaths due to therapeutic complications (TCs) provide important quality of care information for medical providers. In New York City, 463 deaths were investigated by the Office of Chief Medical Examiner and certified with TC as the manner of death in 2003. The TC manner of death is used for fatalities due to predictable complications of appropriate medical therapy. All death certificates and select autopsy, hospital, and investigation reports were reviewed. Data concerning cause of death, contributing conditions, age, race, and sex were extracted. The types of complications and the causes of death were classified into various types of surgical and nonsurgical categories of complications. These included: postoperative infections, pulmonary emboli, and technical and medication complications. The use of TC as a manner of death has benefits and limitations. Without the TC option, one is forced to certify certain deaths (e.g., penicillin anaphylaxis) either as natural or accident. The TC option allows easy identification and tracking of medical complications for public health purposes and also allows more consistent reporting of natural and medical-accidental deaths. In general, complications that occur during emergency surgeries/procedures for natural disease, tend to be certified with a natural manner. The "but for" test may be used to distinguish natural from TC deaths. There are criteria for distinguishing TC from accidents and homicides. TCs that occur during treatment of a potentially life-threatening injury, are superseded by the manner dictated by the circumstances of the initiating injury. The certification of TC usually does not address errors of omission, clinical judgement/management, or missed diagnoses.     

A rapid postmortem cardiac troponin T assay: laboratory evidence of sudden cardiac death

Postmortem examination may be useful in establishing the cause of sudden unexpected death. In many instances, however, limitations of staffing, budget, and time may force the pathologist to triage cases to external examination rather than autopsy. A rapid assay for cardiac troponin T (cTnT) to document suspected cardiac-related deaths may optimize the use of the time and resources of the autopsy pathologist. Peripheral blood was sampled percutaneously before each of 40 autopsies and placed in the well of the Cardiac T Rapid Assay unit in accordance with the included instructions, and the results were read after 15 minutes. The assay result, decedent age, postmortem interval, and evidence of cardiopulmonary resuscitation were tabulated and subsequently correlated with the cause of death. On final sign-out of each of the autopsies, the cause of death was determined to be cardiac-related (n = 20) versus the cause in non-cardiac control subjects (n = 20). This determination was made while the investigators were blinded to the cTnT assay result. Of the 20 cardiac deaths, 17 (85%) showed positive results for cTnT compared with 6 (30%) false-positive results among the 20 control cases; this result was statistically significant according to the chi-square test. In the over-50 age group, the sensitivity of this assay in detecting cardiac-related death was 91%, with a specificity of 86%. Perimortem cardiopulmonary resuscitation did not appear to result in false-positive results. In the appropriate setting, this rapid assay for cTnT can provide valuable data supportive of a cardiac-related death. This inexpensive test may best be used in triaging sudden deaths in persons over 50 to external examination versus complete autopsy.     

Deaths in Unlicensed Alcohol Rehabilitation Facilities,

Non‐English‐speaking people do not always seek medical care through established institutions. This paper reports a series of deaths in unlicensed alcohol rehabilitation facilities serving Spanish‐speaking men. These facilities are informal groups of alcohol abusing men who live together. New members receive various treatments, including administration of ethanol or isopropanol, restraint, and seclusion. We reviewed 42 deaths in unlicensed alcohol rehabilitation facilities in Los Angeles County during the years 2003–2014. Data gathered included age, length of time spent in the facility, blood alcohol and drugs at autopsy, and cause and manner of death. Causes of death included acute alcohol poisoning, alcohol withdrawal, and a variety of other causes. Three cases were considered homicides from restraint asphyxia. The Department of Medical Examiner‐Coroner has worked with the police, district attorney, and State Department of Health Services to try to prevent additional deaths in unlicensed alcohol rehabilitation facilities. Nevertheless, prevention has been difficult.     

Fatal Intoxication with Toluene Due to Inhalation of Glue

Two cases of fatal intoxications with toluene due to glue sniffing are described. In case 1, the autopsy did not indicate cause of death, while in case 2, the cause of death was determined to possibly be due to mechanical asphyxia by drowning. As the decedents had a history of glue sniffing, toxicological analyses were performed. Using gas chromatography with flame ionization detector and gas chromatography/mass spectrometry (GC/MS) with headspace method, toluene was detected in biological samples. Toluene ranged from 3.81 to 20.97 μg/g, with the highest concentrations observed in liver and brain (13.82–20.97 μg/g) in both cases. Based upon this data, the cause of death in both cases was determined to be toluene poisoning. Toxicological investigations are extremely important and should be considered mandatory in all deaths thought to be due to volatile substance abuse, as well as all deaths that are thought to be due to poisoning in young people.     

Fentanyl concentrations in 23 postmortem cases from the hennepin county medical examiner's office

The purpose of this study was to compare blood fentanyl concentrations in fentanyl-related deaths with fentanyl concentrations found incidentally at autopsy, as well as with fentanyl concentrations found in hospitalized patients receiving fentanyl. Between the years 1997 to 2005, 23 fentanyl-positive postmortem cases were identified. Nineteen of 23 (82.6%) cases were deemed to be drug overdoses. Fentanyl alone was responsible for 8 of the 19 (42.1%) overdose deaths. Mean and median fentanyl concentrations were 36 (SD 38) microg/L and 22 microg/L, respectively, range 5-120 microg/L. Seven of the cases were accidental, one undetermined. The remaining 11 of the 19 (57.9%) cases were mixed drug overdoses. Fentanyl concentrations in these cases were 31 (SD 46) microg/L, range 5-152 microg/L. All of the mixed drug overdoses were determined to be accidental. Four cases where fentanyl was considered an incidental postmortem finding were determined to be natural deaths. In hospitalized inpatients (n = 11) receiving fentanyl 2 of the patients receiving fentanyl for chronic pain for more than 3 months had concentrations of 8.5 microg/L and 9.9 microg/L. The other nine inpatient concentrations were less than 4 microg/L. In conclusion, blood fentanyl concentrations found in cases where fentanyl alone was determined to be the cause of death were similar to cases where fentanyl was part of a mixed drug overdose. There was also considerable overlap between fentanyl concentrations in fentanyl-related overdose deaths compared to hospitalized patients being treated for chronic pain. Fentanyl concentrations in postmortem cases must be interpreted in the context of the deceased's past medical history and autopsy findings.     

An Analysis of The Morbidity and Mortality of Diabetes Mellitus in a Forensic Context

To investigate the spectrum of diseases seen in diabetes mellitus in a forensic context, all autopsy reports of diabetic individuals who presented to Forensic Science, South Australia (FSSA), over a 5‐year period from 2005 to 2009 were studied. The leading cause of death was cardiovascular disease (55.0%), followed by unnatural deaths (15.4%) and infections (9.4%). In type 1 diabetics, principal causes of death included cardiovascular disease (44.7%), acute metabolic complications (18.7%), unnatural deaths (17.9%), and infections (8.9%). However, frequencies of these diseases differed in type 2 diabetics, with cardiovascular events responsible for 56.6% of cases, followed by unnatural deaths (15.0%) and infections (10.9%). A larger number of male deaths were seen in all disease categories, except respiratory and gastrointestinal where the frequencies were similar to females. Cardiovascular disease was the leading overall cause of death across all ages except in those under the age of 30 where metabolic complications were more common.     

Minimizing mistakes in clinical diagnosis.

It would be quite reasonable for us to expect the progress made in diagnostic technology to be accompanied by a parallel improvement in diagnostic accuracy. In reality, however, the frequency of misdiagnoses remains the same, despite the fast progress which has been made by medical technology in the last 30 years. Autopsy is the best source of information on diagnostic accuracy. According to one hypothesis, an increase in the number of autopsies performed and the follow-up on them could reduce the number of diagnostic mistakes. In recent times, however, the number of autopsies in comparison with the registered number of deaths has been declining steeply. We studied the autopsy reports for 1997, kept at the archive of the Institute for Forensic Medicine. We only took into account the deaths which occurred within 24 h of admittance to the emergency wards of the Ljubljana University Hospital, including those patients who died subsequently as a consequence of accident or injury. We also included cases of sudden deaths which occurred during operating or within 24 h after it. Following selection, we analyzed 444 out of the total of 921 autopsy reports, for each of which we carried out a comparison between the postmortem diagnosis and the clinical diagnosis, contained in the medical report on the death and the causes of death, which is modeled on WHO recommendations, i.e., the International Classification of Diseases (ICD), and in the medical documents, if any were submitted. Data are entered in these by using the ABC system where: A) direct cause of death, B) are circumstances that influenced the occurrence of death, and C) is original cause of death. The findings were then organized into five groups, depending on the degree to which the clinical diagnosis agreed with the postmortem diagnosis. The first group is comprised of the cases where the clinical and postmortem diagnoses agree completely; the second group is comprised of the cases of partial disagreement on the direct cause of death; the third group is comprised of the cases of disagreement on the original disease; the fourth group, of complete disagreement between the clinical and postmortem diagnoses. The fifth group is comprised of those cases where, under the ABC standards on the classification of diseases, injuries and causes of deaths as specified by the WHO, the documentation was incomplete. A complete agreement between the diagnoses was established in 48.87% of cases; partial disagreement in 22.74%; and total disagreement in 13.5%. 9.68% of cases were classified as falling into group 5. For the three diseases that are among the most common causes of death, we established the percentage of agreement, the percentage of overdiagnosis and the percentage of underdiagnosis. The most frequently underdiagnosed disease (in 61% of cases) was pulmonary thromboembolia; in 15% a thromboembolia was confirmed in autopsy. In 24%, a myocardial infarction was not diagnosed clinically and in 60% the clinical diagnosis of a myocardial infarction was confirmed in autopsy. In 33% a heart failure was not diagnosed during the clinical stages but only in autopsy, in 66% the clinical diagnosis of a heart failure was confirmed in autopsy.     

Increased Lung Weights in Drug‐related Fatalities

This study is of autopsy data for potential validation as to whether increased weights of the lungs support toxic effects of drugs as the cause of death. This retrospective study compared data from 133 deaths resulting from the toxic effects of drugs with previously reported normal lung weights (Toxicol Mech Methods, 22, 2012, 159; Am J Forensic Med Pathol 33, 2012, 368). The lung weights and their standard errors were used in a two‐sample independent t‐test comparing the average drug‐related death weight to the average control weights. To account for multiple comparisons, a Bonferroni‐adjusted alpha level of 0.0125 was used. We are 98.75% confident that the mean right lung weight for female drug‐related deaths is between 227 and 377 g greater than the mean right lung weight for female non‐drug‐related deaths. We are 98.75% confident that the mean right lung weight for male drug‐related deaths is between 245 and 378 g greater than the mean right lung weight for male non‐drug‐related deaths.     

Previously Unreported Complication of Coronary Artery Bypass Grafting: Suture Rupture Resulting in Patient's Death

Traditionally, the manner of death in most hospital autopsy cases is natural, in which death is due to the natural course of disease or reasonably anticipated outcomes of medical interventions. Some cases fall into a potential gray zone between natural and accident, including rare or unanticipated outcomes of medical interventions. We present a case of a patient postcoronary artery bypass graft. Autopsy revealed the proximal anastomosis of the aorta‐to‐first‐diagonal‐coronary‐artery‐to‐second‐obtuse‐marginal‐artery graft was detached from the aorta. A broken suture was present at the disconnected anastomosis, with intact knots but was broken along its length. In‐hospital mortality rates of CABG range from 1% to 3%, with several autopsy studies identifying surgical complications as the cause of death in one‐third of perioperative deaths. No publications were found that described suture rupture as directly relating to the cause of death. This case report describes a previously unreported complication of coronary artery bypass grafting.     

宝鸡市358例法医送检器官的组织病理学分析

目的 分析法医尸体检验后送检器官的病理学特征,总结此类案件的特点.方法 对宝鸡市法医送检358例尸体解剖器官标本进行常规检查并进行组织病理学诊断. 结果 358例中以青壮年男性为主,死亡原因主要为创伤、猝死、中毒.组织学能明确死亡原因250例,无典型组织学病变101例,组织自溶腐败7例.病理诊断以心血管疾病为主,其次为呼吸、神经、消化系统疾病. 结论 法医解剖具有专业特点,与病理解剖不尽相同.组织病理学检验进行死亡原因诊断时,应积极与法医沟通,以充分掌握案情、死亡经过及特定的法医病理学特征.     

The Institution of a Standardized Investigation Protocol for Sudden Infant Death in the Eastern Metropole,Cape Town,South Africa,,

The rate for the sudden infant death syndrome (SIDS) in Cape Town, South Africa, is estimated to be among the highest in the world (3.41/1000 live births). In several of these areas, including those of extreme poverty, only sporadic, nonstandardized infant autopsy, and death scene investigation (DSI) occurred. In this report, we detail a feasibility project comprising 18 autopsied infants with sudden and unexpected death whose causes of death were adjudicated according to the 1991 NICHD definitions (SIDS, n = 7; known cause of death, n = 7; and unclassified, n = 4). We instituted a standardized autopsy and infant DSI through a collaborative effort of local forensic pathology officers and clinical providers. The high standard of forensic investigation met international standards, identified preventable disease, and allowed for incorporation of research. We conclude that an effective infant autopsy and DSI protocol can be established in areas with both high sudden unexpected infant death, and elsewhere. (SUID)/SIDS risk and infrastructure challenges.